Sharing and Learning

Persistent rates of harm justify an ongoing focus on patient safety within Canada's healthcare system. The Canadian Patient Safety Institute connects the public, providers and leaders to share knowledge and learn from each other, and to support patient safety improvement efforts in Canadian hospitals. Learning from the experience of other organizations can accelerate improvement.

13,173

views of specific
Global Patient Safety Alert summaries

100+
countries around the world use Global Patient Safety Alerts

Global Patient Safety Alerts
is a growing repository of

1,400 alerts

7,000 recommendations

26 contributing organizations worldwide

7,477 page views of alert summaries

2,500 views of full alerts

33% conversion rate of page views to full views

Measuring & Improving Hospital Harm

138,000 [5.6%] of all hospitalizations in Canada involve at least one occurrence of harm

Highlights Navigation

Global Patient Safety Alerts

Global Patient Safety Alerts is a publicly-available online collection of indexed patient safety incidents containing more than 1,400 alerts and 7,000 recommendations from 26 contributing organizations around the world.

The program promotes cross-jurisdictional learning, encourages transparency,
and creates a culture of improvement among the global patient safety community. With Global Patient Safety Alerts, contributing organizations publicly share information about identified patient safety risks and effective strategies and actions to manage these risks to prevent harm.

In concert with the Canadian Patient Safety Institute and WHO Collaborating Centre on Patient Safety and Patient Engagement agreement, trends and analysis from Global Patient Safety Alerts (GPSA) were utilized to advise the WHO Collaborating Centre in Human Factors based in Florence, Italy (Centro Gestione Rischio Clinico e Sicurezza del Paziente) on the preliminary design and functionalities of the WHO Global Knowledge Sharing Platform for Patient Safety. This ongoing international collaboration aims to further integrate Global Patient Safety Alerts with international reporting, sharing and learning initiatives.

Key findings of an independent evaluation of GPSA confirmed satisfaction with the tool as a centralized hub amongst users across Canada and globally. The tool has inherent value by providing a platform to encourage sharing of patient safety information and recommendations, and demonstrates value for time invested as an efficient way to gather information, and has the potential to facilitate a culture shift toward improved patient safety. Trend reports and briefings were also developed for committees, organizations and stakeholders in Canada and internationally, to inform priorities and ongoing initiatives.

Hospital Harm Measure

Measuring Patient Harm in Canadian Hospitals is a joint initiative between the Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute to provide a standard approach to measuring and monitoring harm experienced by patients in hospital. Most patients in Canadian hospitals experience safe care, but when harm happens, there is a significant impact on patients, families, the healthcare team, and the health system in general.

The Hospital Harm Measure is designed to help health system leaders to identify patient safety improvement priorities and track progress over time. It measures unintended occurrences of harm diagnosed during a hospital stay that requires treatment or prolonged the patient’s hospital stay, regardless of severity. The measure is structured into 31 clinical groups that capture different types of harm under four broad categories.

The Hospital Harm Improvement Resource and the companion Measuring Patient Harm in Canadian Hospitals analytical report are a compilation of data and evidence-informed practices that link measurement and improvement to support hospitals in their improvement efforts. The online tool is updated regularly, making patient safety information readily available to help hospitals optimize their patient care.

One of our objectives in 2017-18 was to support the use and advancement of the Hospital Harm Measure through webinars and presentations. In collaboration with CIHI, two webinars were delivered. Hospital Harm Measure: Can It Really Be Used For Improvement? was held on September 12, 2017, with 224 participants. The webinar included presentations from Fraser Health, CIHI, Patients for Patient Safety Canada, and the Canadian Patient Safety Institute. The second webinar was held on January 25, 2018, with 177 participants. Learning from leadership: How to champion the hospital harm measure and never events included presentations from Patients for Patient Safety Canada, the Canadian Patient Safety Institute, Health Quality Ontario, and the Canadian Institute for Health Information. Both webinars are archived and available for viewing on the CPSI website.